Children’s Hospitals Caring for Adults During a Pandemic: Pragmatic Considerations and Approaches

There were three levels of consideration for the use of our local pediatric ICU for these patients. First, our institutional policies allow care for adults throughout the system, which we describe in more detail later, in the “Scope of Practice” section. Second, our free-standing pediatric hospital ICUs have accreditation for the care of adults. Third, we developed clear guidelines for subspecialists regarding when adults can safely be admitted or transferred to the pediatric ICU.

Responding to a crisis still necessitates establishing a clear care-escalation plan. An initial barrier may be that some systems do not have a pediatric ICU accredited for care of patients above a certain age. During a crisis, however, as hospital volumes and mortalities rise, states may pursue executive orders, as New York State did, that ease these age restrictions.⁴ Otherwise, we recommend a clear transfer plan to an adult ICU or emergency credentialing and privileging of adult intensivists. Both of these options may pose challenges during a pandemic because adult ICUs will likely be full.

Institutional situation awareness for the identification and mitigation of risks inherent in adult care in a pediatric setting is essential for patient safety. Tracking of admitted adult patients via our electronic health record (EHR) occurs daily by an adult care–team member. Our adult care teams partner with physician safety officers and attend daily institutional multidisciplinary safety huddles to create a shared mental model for the care of adult patients. Daily huddle reports include discussion regarding the number of admitted adults, review of illness acuity, consultative advice on management, and contingency planning for potential decompensation.^5,6 This integration into institutional huddles has been instrumental in proactively identifying hospitalized adults who are at risk for clinical decompensation and mitigating those risks.

Should a pediatric system admit adults to new sites or units, we recommend leveraging preexisting patient safety infrastructure similarly to identify and mitigate risks. If possible, any institutional communication about adult patients should involve adult-trained staff. Mechanisms for tracking patients will depend on local EHRs but are important to guide regular check-ins with providers caring for those patients.

Multiple levels of regulation affect a provider’s scope of practice. The most general of these regulations are state guidelines, followed by local institutional policy. Our institutions require consults for older adults—age varies at our specific institutions—by our adult-care team for assessment of risk and comanagement of adult-specific comorbidities. Additionally, we have agreements with our affiliated adult health facilities that allow in-person adult subspecialty consultation.

While state and institutional policies lay the foundation for pediatric systems considering new adult-care models, provider-level considerations are also needed. Often the patient’s age is a primary consideration, but comorbid conditions also affect the provider’s comfort and ability to care for these patients. We urge practitioners to exercise the full range of their capacities, but also to think critically about the ethical scope of one’s practice. As healthcare providers, it is our duty to hold each other accountable, voice concerns, and advocate to increase health system capacity equitably.⁷ It’s paramount that channels of communication, in-person or virtual, be arranged for supportive adult subspecialist consultation.